For those of us grounded in evidence-based science and medicine, 2008 was a very good year. With new reports debunking “post-abortion syndrome” (PAS),1,2,3 legislative defeats on ideologically driven reproductive health ballot initiatives and a presidential victory that promises a return to scientific rigor and integrity, we have reasons to celebrate.

But anti-abortion advocates are hardly stepping aside. Temporarily spurned by recent scientific and legislative blows, reproductive rights opponents hold on tight to the contention that “abortion hurts women.” On the heels of more evidence refuting a link between abortion and adverse mental health outcomes (see last month's Contraception editorial4), the Family Research Council sponsored a conference in Washington, DC, promoting the spurious connection. Scientific evidence does not seem to have any impact on this cynical approach to swaying public opinion: anti-choice advocacy on college campuses and in federally funded crisis pregnancy centers (CPCs)—“fake” clinics that target pregnant women—continues to promulgate the long-debunked link between breast cancer and abortion. Anti-choice activists are also pressing for the codification of a rule proposed by the Department of Health and Human Services (DHHS) that would make available millions of Title X dollars to unscientific and fear-based abstinence-only education and CPCs.

Undeterred by rigorous science and emboldened by the 2007 Gonzales v. Carhart Supreme Court decision upholding the abortion procedure ban, anti-choice activists may actually be gaining momentum with their “abortion hurts women” argument. The 2010 election cycle may bring more state ballot initiatives chiseling away at a woman's right to a safe and legal abortion. While the science is on our side, science alone, as we've seen over the last 8 years, is not enough to ensure the protection of reproductive rights.

It is difficult for those of us steeped in science to understand how the “abortion hurts women” movement could be gaining traction in mainstream America or how the anti-abortion movement can be promoting the sexist notion that women need to be protected from making their own decisions might be gaining ground. But putting science and sexism aside, for the public—who are often conflicted about abortion but clearly sympathetic to the anxieties and complexities surrounding unintended pregnancy—the “abortion hurts women” message may possess a certain seductive quality. Furthermore, most people (clinicians included) do not have the biostatistics training necessary to discern the methodological flaws and biases in much of the research stating that negative mental health outcomes increase from abortion. Even the highest court in the land seems to be easily influenced by “women-protective” anti-abortion (WPAA) arguments. We only have to look at the language used in the Gonzales v. Carhart decision—which used the terms “regret,” “depression,” and “loss of self-esteem”—to understand the Supreme Court's clear receptivity to anti-abortion advocacy and “abortion hurts women” claims.

Building upon last month's editorial focusing on the science of new abortion-related research, this editorial draws from recent legal publications5,6 to provide a detailed history of the anti-abortion movement's current strategies. Knowledge is power: in addition to knowing and confidently articulating the scientific underpinnings of evidence-based reproductive health practice and policy, it is critical to understand how anti-abortion advocates are positioning their arguments to gain popular support. It is also critical to understand the power of selective individual women's abortion narratives—even if these heartfelt narratives do not support the highest-quality epidemiological data. Armed with greater knowledge of this strategic history, we can more deeply comprehend—and counter—the vast ideological machinery seeking to influence the hearts and minds of the American public into supporting legislation that further restricts abortion access in the United States.

History of the WPAA argument

The early 1990s found the anti-abortion movement at a crossroads: the fetal-focused strategy that served as the movement's political and moral foundation for more than a decade faced sharp criticism inside and outside the movement. The political and legal setbacks resulting from Bill Clinton's election and the subsequent Planned Parenthood v. Casey ruling that preserved Roe proved to be of great concern regarding the movement's effectiveness.5 Also, with respect to the focus on the fetus and the spate of clinic murders, a growing number of anti-abortion activists began questioning the “rescue” paradigm's confrontational and violent tactics whereby activists tried to “save the unborn” until a Human Life Amendment could be ratified.5

Another shift within the movement emerged as growing numbers of activists argued for additional restrictions as a way of “protecting” women from the alleged harms of abortion. While this argument is based on the paternalistic notion that women lack the wherewithal and autonomy to make their own decisions, it was originally packaged by anti-abortion activist Vincent Rue in the early 1980s as “post-abortion syndrome”.5 It then became embraced by women within the anti-abortion movement who disseminated PAS information through the Christian Broadcast Network and other evangelical institutions. Subsequently, CPC volunteers began using PAS narratives to dissuade women from having abortions. PAS proved to be a powerful mobilizing discourse, and CPCs became instrumental in promulgating the syndrome's unvalidated claims.5

Women-focused PAS arguments faced significant resistance from within the anti-abortion movement itself; many leaders felt that the moral forcefulness of protecting unborn life would be lost were the PAS argument to be sanctioned. But as PAS claims gathered strength, the Reagan administration asked anti-abortion advocate Surgeon General C. Everett Koop to weigh in, hoping that if Koop issued a public health edict favorable to PAS, then there would exist a real possibility that the factual basis of Roe could be reassessed and the case could be reopened and overturned.5 Adhering to the strength of the scientific evidence even in the early 1980s, Koop argued that the research was insufficient and that no conclusion could be drawn about abortion's negative health consequences for women. “The pro-life movement had always focused—rightly, I thought—on the impact of abortion on the fetus,” Koop reasoned. “They lost their bearings when they approached the issue on the grounds of the health effects on the mother”.5

By the 1990s, dissension from within the anti-abortion movement enabled its leadership to consider new methods of advocacy that were potentially more successful and persuasive to the “mushy middle” of American public policy: the conflicted 50% of Americans torn between the woman and the fetus who might support new restrictions on abortion access.5 While the scientific merits of the PAS argument did not pass Dr. Koop's muster, the anti-abortion leadership embraced these themes to strategically promote women-centered arguments to use on new and ambivalent audiences.

The emergence of the WPAA argument was fueled by anti-abortion market research. According to John Willke, head of the National Right to Life Committee and pioneer of the 1970s' fetal-focused arguments, he embraced WPAA early in the 1990s when research showed that the movement's fetal-focused arguments were falling on deaf ears.5 The prevailing public sentiment then was that “pro-life people were not compassionate to women and that we were only ‘fetus lovers’ who abandoned the mother after the birth. They felt that we were violent, that we burned down clinics and shot abortionists. We had to convince the public that we were compassionate to women”.5 As more anti-abortion leaders accepted the fact that the conflicted majority of the American public's concerns were focused particularly on the pregnant woman, they embraced a pro-woman strategy within their fetal-focused mission. Tactics based on the belief that women facing abortion were at increased risk of psychological trauma, sterility and breast cancer risks would “help alleviate the ambivalence of voters who were otherwise reticent to criminalize abortion out of concern that it would harm women”.5

As the PAS language made its way from being a centerpiece tactic of CPCs into the overarching “women-protective” strategy embraced by the anti-abortion leadership, it proved persuasive on multiple levels: the personal, the public and the political.6 For women facing unintended pregnancies, PAS arguments attempt to dissuade them from choosing abortion. For public audiences conflicted about abortion and concerned about protecting women's rights, PAS arguments had the effect of co-opting feminist discourse and even public health concerns.6 The inherent seductiveness of these arguments emanates from the potential to be both conflict resolving and seemingly compassionate. Appealing to a conflicted and uninformed public, WPAA arguments can “reassure those who hesitated to prohibit abortion because of concerns about women's welfare that legal restrictions on abortion might instead be in women's interest”.5 In addition, as a “political discourse designed to rebut feminist, pro-choice claims, WPAA came to internalize elements of the arguments it sought to counter—fusing the public health, trauma and survivors idiom of PAS with language of the late 20th-century feminist and abortion rights movements”.6

The effect of WPAA on federal and state legislative efforts

On federal and state levels, WPAA arguments have been supplanting science. As we saw with the Gonzales v. Carhart decision, these specious and emotional arguments influenced the Supreme Court's rationale for limiting late-term abortions. Justice Kennedy wrote:6

“While we find no reliable data to measure the phenomenon, it seems unexceptionable to conclude some women come to regret their choice to abort the infant life they once created and sustained. Severe depression and loss of esteem can follow.”

Criticized both inside and outside the anti-abortion movement for being based on faulty science, the WPAA claims have nonetheless become institutionally entrenched, as evidenced by the Gonzales v. Carhart decision. In addition to acknowledging that they had no good data upon which to validate the hotly disputed notion of PAS, Justice Kennedy and the majority of judges relied heavily on the emotional testimonies of over 1000 women gathered by Operation Outcry, a religion-based project aimed at ending legal abortion.7 These affidavits were first gathered by anti-abortion movement architects seeking to present new evidence of abortion's harm to women as grounds for lawsuits to reopen and reverse Roe. These testimonies came from women who regretted and grieved abortions they claimed to have been coerced or forced into.5

Shifting from the federal to the state perspective, the final report of the South Dakota Task Force to Study Abortion used similar emotional arguments in lieu of sound science to set the stage for and recommend the South Dakota Abortion Ban of 2006.5 As in the Gonzales v. Carhart decision, the task force relied on Operation Outcry's testimonies.5 No effort was made to determine the conditions under which the testimonials were gathered.5 Nor was there an attempt to determine their representativeness or present stories equally as compelling from women whose lives, health and families were positively impacted by receiving compassionate abortion care.

The task force report rejected reports by the more rigorous and objective American Psychological Association and the American College of Obstetricians and Gynecologists and gave authoritative preference to the more methodologically flawed and ideologically driven PAS studies authored by anti-abortion activists.5 So rancorous was the process of writing the report that the anti-abortion chair of the task force, Dr. Marty Allison, voted against the report her own task force produced.5 She then campaigned against the ban because, as she said, the Task Force had opposed motions to restrict the evidence it accepted to “data that is consistent with current medical science and based on the most rigorous and objective scientific studies”.5

Put before voters twice (in 2006 and with slight modifications in 2008), the ban failed.

Implications for clinical practice and policy

Battle-weary reproductive health care providers and professionals found much needed solace in 2008. The nation elected a president committed to comprehensive women's health care and scientific rigor and integrity; voters rejected divisive and harmful women's health-related ballot initiatives; and new, high-quality psychological research showed that abortion does not harm women. Tempting as it might be to rest, we need to remain vigilant in protecting these hard-won reproductive health liberties.

The messages from sound scientific research for health care practitioners and reproductive health professionals are clear:

Armed with the best evidence-based information, health care practitioners need to make sure they are talking about the data with their patients, their colleagues and the media. Many women facing abortion feel alone and fearful. In addition to your counseling staff, use your expertise and commitment to compassionate care and take extra time to talk specifically with your patients about the safety of abortion physically as well as emotionally: they will be happy to hear this directly from you. Bolstering your own expertise and sensibilities, consider suggested language from colleague organizations when talking with undecided colleagues as well as the press about the need for compassionate comprehensive women's health care as a platform for supporting abortion rights.8

Understanding individual women's abortion narratives:

While some individual women's abortion narratives may be based on compelling and genuine stories of pain and regret, the Operation Outcry narratives seem to have been manipulated for strategic ends, working more powerfully than they should have to support the case for restricting abortion. Respect and empathy for the pain of individual women does not, however, justify use of state authority to confuse intimidate, shame or coerce other women seeking abortions, especially as the strongest scientific studies show that abortion does not harm women physically or emotionally.

Be an activist: Work to defund and defrock CPCs:

Purveyors of the “abortion hurts women” argument, CPCs are fake clinics promoting misinformation in order to prevent women from having abortions. Their numbers have burgeoned and could increase if a proposed DHHS rule becomes codified (its fate is unclear at press time)—opening the door for CPCs to receive Title X money, draining an already dwindling pot of federal funds slated to go directly to comprehensive reproductive health clinics. Visit www.arhp.org/topics/abortion for the latest information on emerging abortion policy issues.

Be on the lookout for referrals to CPCs from student health clinics in your area. A recent survey found that 48% of nearly 400 student health clinics at 4-year colleges—approximately 34% of the total student population in the country attending 4-year colleges—routinely referred women thinking they were pregnant to CPCs.9 Although more than 80% of student health centers also referred to comprehensive women's health centers, one health center director noted that some clinics referring to CPCs said that they wanted to give students “all options.” Consider calling student health center directors near you to ensure that pregnant women are only referred to full-service reproductive health care clinics.

Our challenge now is to continue our deeply moral work preserving, protecting and ultimately expanding comprehensive reproductive health care services under a new and friendly administration. Vigilant as we need to be, the future looks much brighter.

Looking for medically accurate, up-to-date, evidence-based educational programming for health care providers and materials for patients on all reproductive health topics, including abortion, contraception, HPV, menopause, menstruation, pregnancy, sexuality? Look no further than the Association of Reproductive Health Professionals (ARHP) – the leading source for trusted medical education and information on reproductive and sexual health.